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Report an Auto Claim
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Auto Loss Claim
General claim form to report an auto loss
Date of Loss
*
MM slash DD slash YYYY
Entity Name:
*
Group or JPA Coverage Name:
Name
*
First
Last
Phone
*
Email
*
Vehicle Make (e.g. Ford, Chevrolet):
*
Vehicle Model (e.g. Taurus, F150, Caprice):
*
Vehicle Engine Size (e.g. v6, v8, 3.0 liter):
Vehicle Year:
*
Odometer Mileage Amount:
Vehicle Identification Number (VIN)t:
*
Department (associated with vehicle, e.g. Police, Public Works)
*
Check all equipment and feature options of vehicle
Automatic Transmission
Manual Transmission
2 Door
4 Door
Anti-Lock Brake System (ABS)
Air Conditioning
CD Stereo
Tilt Wheel
Power Locks
Power Steering
Power Windows
Power Seats
Air Bags
Cruise Control
4-Wheel Drive
Premium Wheels
Luggage Rack
Other
Location of Loss or Accident:
*
Brief Description of Accident or Loss Damages:
*
File Upload
Attach any accident investigation documents, police reports, or other supporting information.
Drop files here or
Select files
Max. file size: 50 MB.
File Upload
Attach copies of two independent estimates of cost
Drop files here or
Select files
Max. file size: 50 MB.
Name of Other Person or Party Involved (if applicable)
First
Last
Phone of Other Person or Party Involved
Address of Other Person or Party Involved
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Insurance Carrier of Other Person or Party
Policy or Member Number:
Phone of Insurance Carrier
